Routine inspection (multi-day)·October 15, 2025

Licensing Program Analyst (LPA) De Leon arrived at 2:45pm to conducted a Case Management Annual Continuation visit to the facility above. LPA met with Administrator Roxandra Whitestine explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan. The facility has EPA approved disinfectants spray and cleaners. The facility has trash bins with lids/covers. The facility has a 30 day supply of PPE. The facility staff have taken annual Infection control and PPE training. Physical Plant & Environment Safety: The facility is a 6 bedroom and 6 bathroom home currently occupying 5 residents and 7 staff, including 3 administrators. The facility is clean, safe and sanitary. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. Laundry room has working washer and dryer. Operational Requirements: The Facility is operating in compliance with fire clearance. Capacity is 6 with 1 non-ambulatory and 5 bedridden with a hospice waiver for 3. The facility has current liability insurance on file. The facility has dual hard wired smoke and carbon monoxide detectors. Continued 809-C Resident Rights Information: All require postings were posted in common areas of facility. Personal rights, Rights to Resident Council, Theft and Loss policy, Non-discrimination notice in addition to a CCL Complaint poster, PIN, License, Hospice Waiver, Emergency Disaster plan and LTCO poster. Planned Activities: The facility offers activities to all residents in care. Activities include arts and crafts, books, magazines, newspapers, TV watching, daily walks, group discussions and communications, and puzzles. The facility has sufficient space to allow for activities indoors and outdoors. Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available in the pantry and garage. Incidental Medical & Dental: Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed for all 5 residents with the Centrally Stored Medication and Destruct Records (CSMDR). LPA inspected 5 residents medications, all medications were in the original containers, prescription labels were not altered, and no medications were expired. Doctors orders were present and dispensing instructions were followed. Disaster Preparedness: The current emergency disaster forms were posted. The facility provided quarterly disaster drills for 2025. The fire extinguishers were charged and dated 03/12/2025. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility does have hospice and home health visits to the facility for residents in care. Facility is completely fenced with self closing and self latching gates. The facility does not have delayed egress. The facility does have 1 residents currently using oxygen and signs are posted. LPA interviewed 1 staff, all residents were sleeping. Exit interview conducted and copy of report printed for Administrator.